Care Manager Social Worker

Monogram Health, Inc.; Savannah (GA); On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

401(k) with employer match

Flexible vacation time

Job summary

Monogram Health, Inc. is seeking a Care Manager, Social Worker in Savannah, Georgia. The ideal candidate will provide in-home and telehealth care management to help patients overcome social and behavioral health challenges. Key responsibilities include collaborating with the care team, assessing patient needs, and assisting with access to healthcare resources. The position requires a Master’s in social work, an LCSW or LMSW license, and involves telephonic visits with some travel. Competitive benefits, including medical and retirement support, are offered.

Qualifications

• Licensed as an LCSW or LMSW in Georgia.
• Experience with care management and chronic illness preferred.
• Basic Life Support (BLS) certification required.

Responsibilities

• Perform in-home and telehealthcare management visits.
• Work closely with Care Team to ensure collaboration.
• Assess and address social determinants of health.

Skills

Empathy

Communication

Relationship Building

Self-starter

Education

Master’s degree in social work

LCSW or LMSW license

Tools

Microsoft Office

Web-based applications

Job description

Job Description: Care Manager, Social Worker

Monogram Health is looking for a skilled Social Worker eager for the opportunity to make a difference in patients' lives. The Care Manager Social Worker is a key member of an integrated Care Team, which includes a Nurse Care Manager and an Advanced Practice Provider. The patients we serve often struggle with multiple serious diseases and behavioral health challenges. Social workers can remove the many economic and behavioral barriers to patients, enabling positive health outcomes.

Your Impact

The care team works with patients face‑to‑face, over the phone, and through telehealth to identify and address social determinants of health. The goal is to build a patient’s social support network, navigate behavioral challenges, and generally help patients through a traumatic diagnosis and life‑changing disease. Your gifts as a healthcare professional are urgently needed. In healthcare systems, the patient has too often become secondary due to processes and incentives that don’t positively impact the patient for the long term. Here at Monogram, we strive to change that narrative by putting our patients and their quality of life at the forefront of what we do.

Roles and Responsibilities

• Perform in‑home and telehealthcare management visits to assess and determine social and behavioral status
• Work closely with Care Team to ensure collaboration and optimal patient outcomes
• Assess social determinants of health needs and develop a plan for addressing them
• Identify, vet, and build relationships with local Community‑Based Organizations
• Educate patients on appropriate resources, assist with referral completion, and follow up for closure outcomes
• Serve as subject matter expert on social determinants for other members of the Care Team
• Complete behavioral, environmental, and social support assessments
• Deliver individual, family and group education on living with chronic illness
• Engage family and social support groups in the education and care of patients
• Assess patients and refer to behavioral health specialists if diagnosis and treatment needed
• Help patients to understand, accept and follow medical and lifestyle recommendations
• Review and document patient updates and progress in care management platform

Position Requirements

• This position involves telephonic visits with some car travel to patients’ homes
• Basic Life Support (BLS) certification is required in this role; the company will support your certification completion through onboarding
• Currently licensed as an LCSW or LMSW in the posted state
• Master’s degree in social work and passed ASWB masters or clinical exam
• Rare domestic travel may be required to Brentwood, TN
• Self‑starter with the ability to work independently with minimal supervision
• Ability to show empathy and quickly build relationships with patients and local CBOs
• Preferred: 2+ years previous experience working in care management and/or with chronic illness
• Excellent verbal communication skills both in person and on the phone

Familiarity with Microsoft Office and mobile phone and web‑based applications is required.

Comprehensive Benefits

• Medical, dental, and vision insurance, employee assistance program, employer‑paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts
• Financial & Retirement Support—Competitive compensation, 401(k) with employer match, and financial wellness resources
• Time Off & Leave—Paid holidays, flexible vacation time/PSSL, and paid parental leave
• Wellness & Growth—Work‑life assistance resources, physical wellness perks, mental health support, employee referral program, and Benefit Hub for employee discounts

About Monogram Health

Monogram Health is a leading multispecialty provider of in‑home, evidence‑based care for the most complex of patients who have multiple chronic conditions. Monogram Health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present—such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders.

Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, healthy eating, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home.

Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum.

Registered Social Worker

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.